There is no need to rush to the cath lab after an abnormal stress test. Optimizing medical therapy and assessing response to therapy does not place patients at greater risk. If the patient’s symptoms and angina do not improve with OMT, then an invasive strategy is appropriate.

In patients with stable moderate – severe coronary disease there were no clinically meaningful differences in outcomes over 4 years in those who were randomized to a conservative versus early invasive strategy.

Clinicians can use the results of the ISCHEMIA trial in a shared decision–making process with their patients. However, we need additional analyses that enable us to use a risk-score tool in order to provide more precise advice to patients about the relative advantages/ risks of the two strategies.

We should wait for a longer-term follow-up to see if any benefits of the invasive strategy become evident over time."